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APPLICATION FOR THE HEARING AID DEALER EXAMINATION
State Form 50685 (R3 / 7-07) Approved by State Board of Accounts, 2006

COMMITTEE OF HEARING AID DEALER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: [email protected]

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

FOR OFFICE USE ONLY
Examination fee Certificate number Date fee paid (month, day, year) Receipt number C.M.

Date of certificate issuance (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Please indicate if you are taking the entire examination for the first time or which portion(s) of the examination you are repeating. Taking the entire examination for the first time. REPEATING THE FOLLOWING PORTIONS: Written Examination Audiometric Oral Portion Instrumentation Portion Medical Oral Audiometric Response Simulator Ear Impression Portion

The date you previously took the examination (month, day, year): ____________________________________ Specify the date of the examination you are applying for (month, day, year): ______________________________
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Residence address (number and street or rural route, city, state, and ZIP code) Telephone number Date of birth (month, day, year) Social Security number* E-mail address Place of birth (city and state or country)

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Business address (number and street or rural route, city, state, and ZIP code) Telephone number Website

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HIGH SCHOOL DIPLOMA, EQUIVALENCY CERTIFICATE OR STATE OF INDIANA GENERAL EDUCATIONAL DEVELOPMENT (GED) DIPLOMA GRANTED BY: NAME OF SCHOOL LOCATION OF SCHOOL DATE OF GRADUATION

STUDENT HEARING AID DEALER CERTIFICATE(S) LIST YOUR CURRENT AND PAST STUDENT HEARING AID DEALER CERTIFICATE(S) CERTIFICATE NUMBER SPONSOR DATES HELD

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LIST ALL DATES YOU HAVE PREVIOUSLY TAKEN THE HEARING AID DEALER EXAMINATION.

LIST ALL STATES, INCLUDING INDIANA, IN WHICH THE APPLICANT HAS EVER APPLIED FOR, OR HELD, A CERTIFICATE TO PRACTICE AS A HEARING AID DEALER TYPE OF LICENSE / CERTIFICATE NUMBER DATE ISSUED CURRENT STATUS

If you answer yes to any of the following questions, explain fully in a sworn affidavit, including all related details. Include the violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a license, certificate or registration issued pursuant to this application. 1. Have you ever had any disciplinary action taken against any hearing and dealer certificate, registration, and / or license held, by a licensing agency or this state, or any other state or jurisdiction? If yes, please list date(s) and details of such action. Yes No

2. Have you ever been convicted of any violation of law relating to drug abuse, controlled substances, narcotic drugs, or any other drugs? If yes, please list date(s) and details of such conviction.

Yes

No

3. Have you ever been convicted of a criminal offense (excluding minor traffic violations) or other offenses as specified in IC 25-1-9? If yes, please list the offense, the court, and the cause number in which you were convicted.

Yes

No

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency to disclose to the aforementioned organizations, person, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Committee from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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